On February 25, 2013, the Department of Health and Human Services (HHS) published a final rule to implement key provisions of the Affordable Care Act (ACA) related to essential health benefits, (EHBs), calculation of actuarial value (AV), and accreditation standards. By way of background, the ACA requires health plans offered in the individual and small group markets -- in and out of new Affordable Insurance Exchanges (Exchanges) -- to offer a core package of “essential health benefits” beginning in 2014. The EHB package must include items and services in at least the 10 broad categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services (including behavioral health treatment); prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services (including oral/vision care). EHB must be comparable to benefits offered by a “typical employer plan.” Under the final rule, EHBs will be defined based on a state-specific benchmark plan, with several options for selection of a benchmark plan. HHS also provides a framework for supplementing the benchmark plan if it is missing any of the statutory benefit categories, and includes safeguards to prevent benefit designs that could discriminate against certain enrollees. In addition, HHS adopted a specific standard for prescription drug coverage, under which an EHB package must cover at least the same number of drugs in each United States Pharmacopeia (USP) category and class as are covered by the benchmark plan for the given state, but in no event less than one drug in every USP category and class.
The final rule also establishes how AV will be calculated under the ACA to facilitate consumer comparisons of plans with similar levels of coverage. The AVs (or percentage of costs the plans cover) will vary by “metal level” – 60% for a bronze plan, 70% for a silver plan, 80% for a gold plan, and 90% for a platinum plan. Also, certain individuals will be eligible to purchase catastrophic-only coverage, and low-income individuals will be entitled to purchase “silver plan variations” with subsidized cost-sharing resulting in AVs of 73%, 87% or 94%. HHS allows a plan to qualify for a particular metal level if its AV is within 2 percentage points of the standard (1 percentage point for silver plan variations). In addition, the final rule adopts a timeline for when issuers offering coverage in Exchanges must become accredited and an application process for accrediting entities seeking to be recognized to accredit issuers offering coverage in any Exchange. An HHS fact sheet regarding the rule is posted here.